of the groove on the posterior surface of the heart between the left
auricle and ventricle. The right border of the opening is on a lower
level than the left and reaches as far downwards as the inferior
vena cava. The opening faces downwards, forwards, and to the left.
In a distended pericardium the apex of the heart is carried for- wards and the contents of the oblique sinus can escape, but with the emptying of the pericardium the ventricles and apex drop backwards and downwards and shut off the oblique sinus from the rest of the pericardial cavity so that it cannot drain through an anterior incision in the pericardium.
Failure to drain this recess properly was, in the writer's opinion, a cardinal factor in the fatal termination of a case of his own.
A left postero-lateral incision would drain this space, and can be made when the trans-pleural route is adopted. Rubber tissue is the best drainage material. The pericardium differs from the pleura and peritoneum in that it cannot be completely inspected and cleansed even if the apex and ventricles are pulled forward so as to expose the mouth of the oblique sinus; this is a cause of difficulty in deciding for or against drainage.
Reanimation of an arrested heart. An epigastric incision is the quickest route though the trans-costal route has been used.
The heart is reached through an incision in the diaphragm, grasped directly near the apex by the thumb and forefinger and the ventricles compressed rhythmically 3040 times a minute. Some surgeons have massaged the heart from the abdomen without in- cising the diaphragm.
Speed is an essential factor ; massage must be commenced without any delay. The circulation has, indeed, been restored after a con- siderable interval, but recovery is not possible unless the organs are in a condition to benefit from the influx of blood ; the nervous system suffers irreparable damage from cessation of circulation in about 15 minutes. The heart muscle retains its power of contraction a long time; according to Kuliabko (quoted from L. Wrede Arch. f. kl. Chi. Bd. IOI (1913) S. 835) contraction can be induced in the isolated human heart by passing through it a stream of warm oxy- genated fluid even 24 hours after death.
Intra-cardiac injection of excitant substances such as stro- phanthin, adrenalin, and caffeine has been used either alone or in conjunction with massage, as also injection of saline solution or defibrinated blood, either intravenously or into the heart; with a view to rapid restoration of circulation through the coronary arteries injection through the carotid towards the heart has been suggested. Fieri reported 76 cases of heart massage. In 19 success was complete and permanent, in 16 partial and temporary, and in 41 failure was complete. In the successful cases the interval between cessation of the heart's action and the start of massage was from 2 to 15 minutes (RevistaOspedalera, April 15 1913, vol. iii., No. 7).
Wrede, in order to decide whether massage of the heart effected an artificial circulation of the blood and not a mere to and fro movement in which the pressure in veins and arteries was equal, injected colouring matter into the external jugular vein after death and then massaged the heart. He found the colouring matter had penetrated into the vessels of the portal circulation, and this he con- sidered proved that capillary resistance had been overcome, but that it was conceivable that it was in the reverse direction.
Proposed operations for certain valvular lesions. Sir Lauder Brunton (Lancet, 1902), witnessing the autopsy on a young girl who had died from uncomplicated mitral obstruction was led to reflect on the possibility of surgical relief in similar cases, and made ex- periments bearing on the subject. Carrel and Tuffier pursued the enquiry further (Presse Medicate mars 1914) and concluded that pure mitral stenosis, certain forms of stenosis of the aortic orifice and of the pulmonary artery, might derive benefit from surgical intervention. Schepelman (Arch. f. kl.chi., 1912, vol. 97) suggested that congenital tricuspid stenosis might be amenable to operation.
The following operations were experimentally performed by Carrel and Tuffier: Internal yalvulotomy, external valvulotomy, auriculo-ventricular anastomosis, arterio-ventricular anastomosis, section of the mitral valve indirectly through the carotid artery after the manner of an internal urethrotomy, resection of valves. They effected derivation of the blood current by means of a piece of vein with the formation of an artificial valve. An ingenious method which they term " patching " was tried: a square piece of vein is sutured along three sides of its sides over the site of the arterial opening it is desired to enlarge, a small knife is insinuated beneath the patch at the unsewn edge, the vessel beneath incised, and the suture of the patch completed.
The only reference to operations for valvular disease in man which the writer has seen is by Turner, who mentions two cases (Fifth Congress of Int. Soc. of Surgery, Brussels, July 1920): " I observed, in a young man, a grave and rapidly progressive aortic-stenosis. On the repeated request of his physician I decided to explore it. The vibration was intense: I reached the stenosis and very easily carried out a gradual dilutation by slowly introducing the little finger into the strictured ring, the vibrations under the finger being intense; I abstained from trying to divide the stricture as I did not consider experimental enquiry sufficiently advanced. I did not expect to attain any result. The patient was well in a few days; he improved temporarily and is still alive. I saw him three months ago."
Doyen attempted cardiotomy on a patient believed to be suffering
from mitral stenosis; at the operation an inter- ventricular communi- cation was found and the patient died in a few minutes.
Tumours of the heart and paracardiac tumours. A primary tumour of the heart has not yet been diagnosed during life, and the symptoms to which they give rise having been referred to valvular lesions or to angina pectoris, but some forms of benign tumour are anatomically operable. Certain paracardiac tumours, mediastinal dermoids among others, adhere intimately to the pericardium and cause cardiac embarrassment.
Turner has successfully operated on one such case. Removal of the 2nd and 3rd costal cartilages disclosed a dermoid cyst as large as two fists filled with sebaceous matter, it was totally adherent and within it the aorta, the auricle and ventricle could be seen beating, and formed part of the wall without the interposition of the peri- cardium, part of the wall was calcareous and constricted the left half of the vascular pedicle. The cyst was drained, and six months later the calcified portion of its wall was broken up piecemeal. The patient recovered. Clerc and Duval (Bull, et Mem. de la Soc. de Chi. vol. xlvii., 1921, p. 200) published a successful case in which a dermoid cyst was completely removed from the mediastinum ; the pleura was closed without drainage. On the second day after opera- tion 500 c.c. of sterile fluid were removed by aspiration, after which there was no further complication.
Literature and statistics. The paper by Fisher in Langenbecks Archiv., vol. ix., (1868) and the article by Matas in Keen's Surgery (1909) give a full account of the subject and its literature as known at the respective dates; by contrasting them the great advance of knowledge will be evident. In Sir Charles Ballance's Bradshaw Lecture, 1919, a table is given of 152 cases of operation on the heart and pericardium subsequent to 1912 (with references) collected from literature; of these 104 recovered and 48 died, showing a mortality of 3 I- 57%- In 1920 Tuffier, in a paper at the Fifth Int. Cong, of Surgery at Brussels, referred to 305 cases with a mortality of 49-6%. Statis- tics give some idea of the amount of work that has been done, but so many different conditions are present and the probability that many unsuccessful cases are not recorded is so great, that they are not reliable in estimating the risks of operation. In the Lancet of May 7 1921 a case is quoted from the Journal of the American Med. Assn. of Feb. 19 1921 in which E. M. Freeze successfully sutured a wound of both ventricles.
II. LUNGS AND PLEURAE. It was until recently believed that opening the pleural cavity without the aid of differential pressure might be fatal, and that incision or even handling of the lung would cause severe haemorrhage; these fears long retarded the progress of intra-thoracic surgery. Experience has shown that an open pneumothorax on one side is without grave danger, that the once-dreaded pulmonary collapse is an assistance rather than otherwise to the surgeon, and that bleeding from the lung is readily arrested by suture. The scope of intra-pleural surgery has been considerably extended, not so much by any new dis- covery as by the application of the general principles of surgery.
Operations on the lung and pleura are now undertaken (a) for injuries, (b) for certain diseases. The pleural cavity is opened and the lung exposed by resection of a rib or ribs or by rib- spreading with, or sometimes without, division of one or more ribs or cartilages. Osteo-plastic flaps are mostly abandoned.
Injuries. The experience of the World War has shown that the ideal treatment of a wound (gunshot or other) is mechanical cleansing, removal of all foreign bodies and devitalized tissue, and repair by suture. This should be the aim of the surgeon in dealing with wounds of the lung, and the complete operation for this condition would be excision of the parietal wound, removal of all blood and clots from the pleura, exposure of the lung, re- moval of any foreign body, cleansing and repair of the pulmonary wound and closure of the thorax.
Operation for retained projectiles in the lung is fully described and discussed in a paper by Sir B. Moynihan in the Brit. Journ. of Surgery, April 1920. He recommends the open method of Duval and the separation of all adhesions, however dense, as the first step of the intra-pleural operation. Duyal's lung forceps are used for fixing the lung and bringing the area of incision to the surface. The special- ly dangerous region is the root of the lung " the number of vessels is great and their size formidable. A wound of the root of the lung should be inflicted with extreme caution, for if a vessel is wounded it is exceedingly difficult to arrest the haemorrhage. It is almost im- possible to secure the vessel and to ligate it in the ordinary manner. If a suture is passed round the vessel it is likely that other vessels will be wounded by it. For this reason many of the French surgeons advise plugging the wound with gauze, which is left in position for two or three days. The root of the lung is almost immobile. The operator must go down to it; he cannot bring the parts nearer to him. All the steps of the operation can, and should, be visible to the surgeon nothing need be done in the dark; but the remoteness and
